Joel Paris, M.D.-The Journal

Monday, April 15, 2002

What is Borderline Personality Disorder?
Personality disorders affect about 10% of the general population. This group of mental disorders is defined by maladaptive personality characteristics that have a consistent and serious effect on work and interpersonal relationships. DSM-IV defines ten categories of personality disorder. Of these, Borderline Personality Disorder (BPD) is the most frequent in clinical practice. BPD is also one of the most difficult and troubling problems in all of psychiatry.
The term "borderline" is a misnomer. These patients were first described sixty years ago by psychoanalysts who noted they did poorly in treatment, and therefore theorized that this is a form of pathology lying on the border between psychosis and neurosis.
Although we no longer believe that patients with BPD have an underlying psychosis, the name "borderline" has stuck. A much more descriptive label would be "emotionally unstable: personality disorder." The central feature of BPD is instability, affecting patients in many sectors of their lives.
Thus, borderline patients show a wide range of impulsive behaviors, particularly those that are self destructive. They are highly unstable emotionally, and develop wide mood swings in response to stressful events. Finally, BPD may be complicated by brief psychotic episodes.
Most often, borderline patients present to psychiatrists with repetitive suicidal attempts. We often see these patients in the emergency room, coming in with an overdose or a slashed wrist following a disappointment or a quarrel.
Interpersonal relationships in BPD are particularly unstable. Typically, borderline patients have serious problems with boundaries. They become quickly involved with people, and quickly disappointed with them. They make great demands on other people, and easily become frightened of being abandoned by them. Their emotional life is a kind of rollercoaster.
What Causes BPD?
We are only beginning to understand the causes of BPD. As in most mental disorders, no single factor explains its development. Rather, multiple risk factors, which can be biological, psychological, or social, play a role in its etiology.
The biological factors in BPD probably consist of inborn temperamental abnormalities. Impulsivity and emotional instability are unusually intense in these patients, and these traits are known to be heritable. Similar characteristics can also be found in the close relatives of patients with BPD. Research suggests that the impulsivity that characterizes borderline personality might be associated with decreased serotonin activity in the brain.
The psychological factors in this illness vary a great deal. Some borderline patients describe highly traumatic experiences in their childhood, such as physical or sexual abuse. Others describe severe emotional neglect. Many borderline patients have parents with impulsive or depressive personality traits. However, some patients report a fairly normal childhood. Most likely, any of these scenarios is possible. Borderline pathology can arise from many different pathways.
The social factors in BPD reflect many of the problems of modern society. We live in a fragmented world, in which extended families and communities no longer provide the support they once did. In contemporary urban society, children have more difficulty meeting their needs for attachment and identity. Those who are vulnerable to BPD may have a particularly strong need for an environment providing consistent expectations and emotional security.
Most likely, BPD develops when all these risk factors are present. Children who are at risk by virtue of their temperament can still grow up perfectly normally if provided with a supportive environment. However, when the family and community cannot meet the special needs of children at risk, they may develop serious impulsivity and emotional instability.
The Course of BPD
Borderline personality disorder is an illness of young people, and usually begins in adolescence or youth. About 80% of patients are women. BPD is usually chronic, and severe problems often continue to be present for many years. About one out of ten patients eventually succeed in committing suicide. However, in the 90% who do not kill themselves, borderline pathology tends to "burn out" in middle age, and most patients function significantly better by the ages of thirty-five to forty. The mechanism for this improvement is unknown. However, other disorders associated with impulsivity, such as antisocial personality and substance abuse, also tend to burn out around the same age.
The level of long term improvement in borderline patients varies a great deal. A minority will develop a successful career, marry happily, and recover completely. A minority will continue to be highly symptomatic into middle age. In the majority of cases, both impulsivity and emotional instability decline over time, and the patient is eventually able to function at a reasonable level.
BPD can be very burdensome for the patient's family. It is particularly difficult to deal with suicidal threats and attempts. Parents often wonder if they are at fault for the patient's condition and patients sometimes blame their parents, and some therapists will agree with them. However, the scientific evidence does not justify the conclusion that the family carries the primary responsibility for the development of borderline personality disorder.
The Treatment of BPD
There is no specific or universal method of treatment for BPD. At times, drugs can take the edge off impulsive symptoms. For example, some patients do better with low dose neuroleptics. However, no psychopharmacological agent has any specific effect on the underlying borderline pathology. In spite of the association between impulsivity and low serotonin activity, specific serotonin reuptake inhibitors (such as fluoxetine) rarely produce a dramatic improvement.
The mainstay of treatment for BPD has always been, and continues to be psychotherapy. However, because of their impulsivity, about two thirds of borderline patients drop out of treatment within a few months. Those patients who stay in therapy will usually improve slowly over time.
The chaos that characterizes border line patients makes them difficult cases for therapists. A patient with BPD may be continuously suicidal for months or years. Moreover, many of the same problems that patients have with other people arise in their relationships with helping professionals.
A number of different therapeutic methods have been tried with borderline patients. The largest clinical literature has come from psychoanalytically oriented therapists. Traditionally, psychotherapists focus on building a strong working alliance with the borderline patient. When the therapeutic relationship provides a safe haven, it is easier to work on developing better relationships with other people.
Most of the work in psychotherapy consists of helping patients to be less impulsive, and to exercise better judgment in their management of their personal lives.
In view of the frequency of reported childhood trauma in borderline patients, some therapists have suggested that BPD should be thought of as a form of post traumatic stress disorder. These clinicians tend to focus on uncovering negative events so as to help patients process them. However, there is no evidence that these methods are successful. In fact, there is some reason to suspect they can make patients worse, by focusing too much on the past, and not enough on the present. In addition, borderline patients can be particularly prone to develop false memories in psychotherapy.
Recent research suggests that cognitive-behavioral therapy, which has developed methods targeting impulsivity and emotional instability, may be particularly appropriate for borderline patients. Studies of a behavioral treatment specifically developed for patients with BPD, "dialectical behavior therapy," indicate that this approach can bring suicidality under control within one year. However, we do not know whether this method provides an effective long term treatment for the disorder.
BPD creates enormous suffering in those afflicted with it. Most patients describe a continuous state of emotional chaos, swinging from extremes of depression, anger, and anxiety. Borderline patients often need to feel suicidal in order to know that they can escape from their dysphoric feelings. The road to recovery in BPD is often long and difficult. However, borderline patients are often attractive and productive people. When treatment is successful, the patient, the therapist, and the family can all feel that it was well worth the trouble to see things through.
We need to conduct more research on the causes of BPD in order to develop more rational methods of treatment. In the future, we will probably have methods of pharmacotherapy and psychotherapy specifically designed for this challenging patient population. In the meantime, the best hope for most patients consists of linking up with a good therapist.
--------------------------------------------------------------------------------
Joel Paris, M.D.